Joe Higgins from Rocky Mountain MIRECC podcast interviewed me at the American Association for Suicidology annual conference as part of series on Zero Suicide, which includes interviews with Julie Goldstein Grumet, Ph.D. and Brian K. Ahmedani Ph.D. Links below will take you to the interview in whichever player you prefer.

A new take on Zero Suicide and Risk Formulation with Tony Pisani, Ph.D. (18 minutes)

We are often asked how standardized instruments or interviews like the Columbia Scale (C-SSRS) fit into the risk formulation framework that my colleagues and I developed (Pisani, Murrie, & Silverman, 2015).

A couple of weeks ago, I had the privilege of presenting with Greg Brown and Leah Harris in a Zero Suicide webinar titled, "Screening and Assessment for Suicide in Health Care Settings: A Patient-Centered Approach" The recording of the webinar and slides are now posted on the ZS website. My part of the webinar starts at around 28:00 minutes, but watch the whole thing; my co-presenters are top notch. In my 20-minute portion, I introduced the risk formulation model I've been working on with colleagues Daniel Murrie and Mort Silverman. This model is the centerpiece of Commitment to Living and is also incorporated in the most recent revision of the Suicide Prevention Resource Center's flagship workshop, Assessing and Managing Suicide Risk: Core Competencies for Mental Health Professionals.

James Fowler does it again. He has just published another terrific and useful paper, "Core principles in treating suicidal patients." This makes a terrific companion piece to his previous paper describing "guidelines for imperfect assessments" which I have raved about and recommend all the time. The current paper is elegant and straightforward. Dr. Fowler provides a rationale, evidence, and a treatment example for three core principles:

alliance building

enhancing curiosity about the function of suicidal thoughts and urge

enhancing experience and epxression of intense emotions

Voila! What more do you want? You have to put Dr. Fowler's name on your search engine alert list! I just added it to the reference list that I will distribute at my next Commitment to Living workshop.

I'll be speaking in Lewiston Idaho next week at the St. Joseph's Region Medical Center's annual Rural Mental Health Symposium. I know from IP addresses that we have readers in the Northwest. If any are in the Lewiston area, please come.

I have been thinking and learning a lot about suicide risk in cancer patients because I am working with some colleagues in cancer control and prevention to identify and respond to educational needs among cancer care professionals. Related to this topic, readers might be interested a nice article by Kendal & Kendal published last year in the journal Crisis (abstract linked below). This article titled, Comparative Risk Factors for Accidental and Suicidal Death in Cancer Patients makes a number of insightful observations about risk in cancer patients based on statistical analyses of a large and impressive NCI dataset (SEER, 1973-2000).

Among the observations I found most interesting was that the well-documented increased risk of suicide in the year following cancer diagnosis, which is commonly attributed to psychological factors, may in fact be more closely related to physical factors, i.e. rapid deterioration of symptoms in rapidly progressing disease. Because many of the candidate psychological factors were not measured in this study, the question cannot be studied directly, but I found the findings compelling enough–and their treatment in the article careful enough–to warrant consideration. In the end, it may be very difficult to tease apart psychological distress from physical suffering, but I appreciate this article drawing attention to the question.

In a 6-month follow-up study of 119 hospitalized adolescents, Yen and colleagues found that many traditional risk factors including psychiatric diagnoses and past attempts failed to prospectively predict suicidal behavior. Other factors, which the authors called "cross-cutting" (because they cut across many disorders) were more potent.

These findings have direct clinical implications and indirect prevention implications. From a clinical perspective, clinicians must be cautious in applying population-generated risk factors to clinical risk formulation. Clinical training in risk formulation should emphasize dynamic factors over diagnoses and history and involve thoughtful synthesis of a wide range of factors and individual circumstances. From a broader prevention perspective, the study provides additional building blocks in the argument for focusing on cross-cutting constructs such as emotion self-regulation in suicide prevention (see our recent population-based study identifying emotion self-regulation as a critical construct for youth suicide prevention). This emphasis on "cross-cutting" constructs has interesting intersections with NIMH's effort, represented by the Research Domain Criteria (RDoC) to shift research away from DSM diagnostic categories toward dimensional assessment of more fundamental and biologically verifiable constructs. These findings are also congruent with (though they do not directly support) strategies that reach further "upstream" in adolescent development to build core "cross-cutting" protective factors.

My colleagues and I conducted a study examining associations between self-reported suicide attempts, emotion regulation difficulties, and trusted youth–adult relationships among 7,978 high-school students. The results have been pre-published online in the Journal of Youth and Adolescence. Our findings point to adolescent emotion regulation and relationships with trusted adults as complementary targets for suicide prevention that merit further intervention studies. We argue that reaching these targets in a broad population of adolescents will require new delivery systems and “option rich” (OR) intervention designs. Print publication will follow later this year.

The New York Times published an article this week that readers of this blog should be aware of. The article is titled, Study Questions Effectiveness of Therapy for Suicidal Teenagers. The article reports on results from a study published in JAMA Psychiatry (the new name for Archives of General Psychiatry) by Matthew Nock and a team of outstanding scientists. The NYT headline is based mostly on the finding that:

...suicidal adolescents typically enter treatment before rather than after the onset of suicidal behaviors. This means that mental health professionals are not simply meeting with adolescents in response to their suicidal thoughts or behaviors, but that adolescents who are clinically severe enough to become suicidal more typically enter treatment before the onset of suicidal behaviors. There is no way to know from the NCS-A data how often this early intervention prevents the occurrence of suicidal behaviors that would otherwise have occurred but were not observed in our data. It is clear, though, that treatment does not always succeed in this way because the adolescents in the NCS-A who received treatment prior to their first attempt went on to make an attempt anyway. This finding is consistent with recent data highlighting the difficulty of reducing suicidal thoughts and behaviors among adolescents. (Nock et al, (2013) Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents, JAMA Psychiatry, ePub ahead of print, p. E9)

The Nock article is hefty and I have not yet fully digested it. So I will withhold judgement about the article's conclusions, and about whether the NYT article reported them fairly and accurately. However, I am pleased about the discussions that this study and the Times article have the potential to stimulate. One conversation is about how to improve the quality and effectiveness of treatment for at-risk adolescents. This is not a new conversation, but continues to be an important one. Another conversation I hope this NYT article will stimulate relates to broadening our view of what suicide prevention is. With some important exceptions (including some here in New York State), the dominant strategy in suicide prevention has been to identify youth who are suicidal and get them into treatment. As my mentor, Peter Wyman has demonstrated (Wyman et al, 2008) and this Nock article brings to the surface, these 'identify and refer' strategies are limited by a number of factors, including availability and acceptability of services, the length of time adolescents remain in services, the effectiveness of therapy, and adolescents' tendency not to disclose suicide concerns to adults (Pisani et al 2012). While I am committed as ever to improving the quality of screening, assessment, and treatment for at-risk adolescents (and help to train hundreds of clinicians each year), I do not expect that treatment services alone will be sufficient for reducing suicide in the population. For this reason, in my research I am pursuing youth suicide prevention strategies aimed at addressing risk and protective processes further "upstream" (a term I learned from Dr. Wyman). In an article soon to be published, I argue that we need new interventions that can flexibly reach a broader population of adolescents further upstream and that these will require making use of new delivery systems, designs, and technologies.

I look forward to studying the Nock article and to participating a discussion that could help stimulate the field to re-examine what "prevention" really means. Substance abuse prevention does not start with finding kids who are already taking drugs. Fire prevention doesn't start with the fire department. We need great fire departments and well-trained fire fighters, but fire protection engineering and public education make major conflagrations rare. Likewise, youth suicide prevention must focus more broadly then on adolescents who are already suicidal.

Clinicians, school personnel, parents and other adults share at least one thing in common: none of us can read minds. The only way we're going to know if an adolescent is considering suicide is if they tell us. My colleagues and I conducted a study examining some key correlates of help-seeking among adolescents who had seriously considered suicide. The results have been published in the Journal of Youth and Adolescence.

Assessments are human encounters, a chance to demonstrate compassion and instill hope. A small qualitative study by colleagues in Manchester, England illustrates the importance of caring assessments and of considering the social and family context of the individual in planning. Hunter et al conducted 13 initial interviews and 7 follow-up interviews with individuals who had been hospitalized related to some form of self-injurious behavior. Their findings are highly congruent with the hallmarks of patient and family-centered response to suicide risk that I have proposed. The article (linked below) outlines a number of lessons about what matters to patients, which boils down to having meaningful interactions with clinicians who: convey empathy, understand problems from their perspective, inspire hope, and develop plans/referrals that match their preferences and social context. None of this is rocket science; it's harder than that. Hearing how much it matters to patients should encourage all of us with a commitment to living to continually refine our approach to assessment.